Governments with universal healthcare systems are increasingly bemoaning the costs of their systems and the need to contain these costs if affordable healthcare services are to be sustained into the future. In a bid to reduce the costs of healthcare, politicians and bureaucrats have championed the need for reform. Although avoiding the language of rationing, the kinds of ‘reforms’ being championed (eg. greater government regulation of universal health coverage, reducing reimbursement for medical costs, cutting funding to public hospitals) seem however, to be more concerned with restricting universal healthcare coverage, rather than reforming it.
The rhetoric of healthcare reforms has also had a political ideological objective shifting the provision of and accountability for public healthcare services to private sector providers. This objective has been pursued despite experts warning that such a shift will ultimately lead (and in some cases has already led) to inequities and unjust disparities in access to healthcare and related health outcomes, especially in vulnerable populations who cannot afford private health insurance.
Australia has not been immune from ideologically driven machinations about the sustainability of its universal healthcare scheme, ie. Medicare. Despite health expenditure in Australia reportedly reaching a record low for the period 2012-2013, there has been a political campaign of spreading false and misleading information about Medicare’s sustainability (Keast 2015).This misinformation has included ‘blaming’ vulnerable populations (eg. an ageing demographic, the ‘undeserving poor’) for their allegedly disproportionate over-utilisation of public healthcare services and the need to curb this costly ‘wanton’ demand. What has been overlooked in this situation, however, is that a key driver of the spiraling costs of healthcare is not the over-utilisation of services by people in need, but rather ‘the use of wasteful tests and treatments’ prescribed by doctors (Tilburt & Cassel, 2013) together with the rising costs of drugs (driven by the business behaviours of the pharmaceutical industry) and medical technology, particularly in hospitals. Also overlooked is the problem of language and the tendency to treat the terms ‘healthcare’, ‘hospital care’, and ‘medical care’ as being synonymous, when they are not. Failure to distinguish what each of these terms refers to unnecessarily muddles debate about what healthcare reforms are needed as well as where and how these should occur.
Question of nursing ethics
The ethics of healthcare rationing has been the subject of debate for decades. This debate has primarily rested on the issue of whether it is ever acceptable to ration healthcare and, if so, on what grounds. It has also prompted unresolved controversies about the interests of individuals versus the collective interests of society in accessing limited healthcare resources and how best to balance these competing interests. Meanwhile, those working at the intersection of health policy and ethics have attempted to persuade pundits that the issue should not be about rationing and compromise, but about justification and appropriateness (Asch & Ubel 1997). In other words, it should be about rationalising (justifying) healthcare, not rationing (arbitrarily restricting) it. Here the question arises: What stance should the nursing profession take in response to this vexed issue?
Taking a stance
In 2015, the theme Nurses: A force for change – care effective, cost effective has been adopted for International Nurses Day. In a media release announcing this theme, David Benton, ICN Chief Executive Officer, contends that because nurses are the single largest group of health professionals they ‘can have an enormous impact on reducing health costs and increasing quality of care’ (www.icn.ch/). In light of this, the ICN urges all nurses and policy makers to ‘focus on the nursing role as a key priority and determinant for achieving equity, delivering universal health coverage and ultimately improving health outcomes globally.’ To aid in this task, the ICN has prepared a toolkit for examining ‘the current issues around health system financing and the value of nursing’ (available at: www.icn.ch/).
Achieving equity, delivering universal health coverage and ultimately improving health outcomes is going to require a collective effort on the part of a range of stakeholders, not just nurses. It is also going to require much more than a ‘Choosing Wisely’ campaign (soon to be launched in Australia – see O’Callaghan et al. 2015), the aim of which is to encourage doctors to engage in ‘parsimonious medicine’ and to make better treatment choices, reduce risks and, where able through prudent decision making, reduce costs (Tilburt & Cassel, 2013). As argued previously in this column (ANJ 2010, April & August issues) what is also required is a cultural revolution in thinking about: the values of health and healthcare, ageing and death, the kind of reform that is required to ensure a healthcare system that is responsive and well-coordinated to meet the needs of current and future generations, and whether the solutions being proposed by authorities will be effective and just.
The nursing profession needs to think deeply about these issues. Meanwhile, it is incumbent on nurses in Australia to campaign to promote, protect and preserve Australia’s Medicare scheme. This includes taking collective action to: affirm the value of Medicare, expose the misinformation that is being spread about its sustainability, interpret attacks on it as unfair, and to discredit official channels that are distorting the issues at stake in favour of progressing an ideologically driven agenda for dismantling universal health coverage in Australia and dismissing its humanitarian objectives.